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Comparative Study
. 2025 Aug 26;334(8):702-713.
doi: 10.1001/jama.2025.11661.

Impact of the MISSION Act on Quality and Outcomes of Major Cardiovascular Procedures Among Veterans

Jingyi Wu  1   2 , Genevieve P Kanter  1   3   4 , Todd H Wagner  5   6 , Danny Chu  7   8 , John P Cashy  7 , Jason M Prigge  1 , Thomas J Glorioso  9 , Natalia Rahman  10   11 , Nandini Murali  10   11   12 , Jay Giri  1   13   14 , Ashwin S Nathan  1   13 , Stephen W Waldo  9   11   15   16 , Peter W Groeneveld  1   2   14
Affiliations
Comparative Study

Impact of the MISSION Act on Quality and Outcomes of Major Cardiovascular Procedures Among Veterans

Jingyi Wu et al. JAMA. .

Abstract

Importance: The Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded opportunities for veterans to obtain care outside the VA. However, the impact on health care outcomes is uncertain.

Objective: To measure the MISSION Act's impact on travel times and outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and aortic valve replacement (AVR).

Design, setting, and participants: This retrospective difference-in-differences cohort study included veterans receiving nonemergent/nonurgent PCI, CABG, or AVR between October 2016 and September 2022 in non-VA hospitals under MISSION Act coverage or in VA hospitals in the 48 contiguous US states or the District of Columbia. Analyses were conducted in 2023-2024.

Exposures: Veterans eligible for non-VA care under the MISSION Act by living far from ( >60 minutes) the nearest VA medical center vs veterans living near (≤60 minutes) a VA medical center.

Main outcomes and measures: Major adverse cardiovascular events (MACE), defined as rehospitalization for cardiovascular cause or mortality within 30 days of the procedure, and travel times for care were the primary outcomes.

Results: The cohort comprised veterans receiving PCI (n = 43 000; 42 066 [98%] male; mean [SD] age, 69 [8.8] years), CABG (n = 23 301; 22 197 [98%] male; mean [SD] age, 69 [7.7] years), or AVR (n = 14 682; 14 336 [98%] male; mean [SD] age, 74 [9.6] years). After MISSION implementation, mean PCI travel times increased by 1.3 minutes for near patients and decreased by 29.2 minutes for far patients (difference in differences, -30.5 minutes; P < .001). Mean CABG travel times increased by 9.4 minutes for near patients and decreased by 18.1 minutes for far patients (difference in differences, -27.4 minutes; P < .001). Mean travel times for AVR increased by 10.0 minutes for near patients and decreased by 23.0 minutes for far patients (difference in differences, -33.1 minutes; P < .001). After MISSION implementation, mean PCI MACE rates decreased by 0.5 percentage points for near patients and increased by 2.3 percentage points for far patients (difference in differences, 2.8 percentage points; P <.001). Mean CABG MACE rates decreased by 6.5 percentage points for near patients and increased by 1.6 percentage points for far patients (difference in differences, 8.1 percentage points; P < .001). AVR MACE rates were not statistically different between the groups (P = .45).

Conclusions and relevance: MISSION Act implementation was associated with substantial decreases in travel times among veterans who became geographically eligible for non-VA care. For these patients undergoing PCI or CABG, MISSION Act implementation was also associated with worsened 30-day MACE rates.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kanter reported receiving grants from the Department of Veterans Affairs (VA) during the conduct of the study. Dr Wagner reported grants from VA, National Institutes of Health, the Agency for Healthcare Research and Quality, Heinz Foundation, and Robert Wood Johnson Foundation outside the submitted work. Dr Giri reported personal fees from Inari Medical, Boston Scientific, Endovascular Engineering, and Edwards Lifesciences outside the submitted work. Dr Nathan reported receiving grants from Edwards Lifesciences, Biosense Webster, American Heart Association, Society for Cardiovascular Angiography and Interventions, and Boston Scientific outside the submitted work. Dr Waldo reported grants from VA Health Systems Research and grants from National Institutes of Health during the conduct of the study. Dr Groeneveld reported receiving grants from VA, Health Resources and Services Administration, and Agency for Healthcare Research and Quality during the conduct of the study. No other disclosures were reported.

References

    1. Kullgren JT, Fagerlin A, Kerr EA. Completing the MISSION: a blueprint for helping veterans make the most of new choices. J Gen Intern Med. 2020;35(5):1567-1570. doi: 10.1007/s11606-019-05404-w - DOI - PMC - PubMed
    1. Veteran community care eligibility fact sheet. VA Office of Community Care. August 30, 2019. Accessed October 11, 2024. https://www.va.gov/files/2024-12/VA-FS_CC-Eligibility.pdf
    1. Community care VA fee schedule. VA Office of Connected Care. Updated June 12, 2025. Accessed July 2, 2025. https://www.va.gov/COMMUNITYCARE/revenue-ops/Fee-Schedule.asp
    1. Ogrysko N. MISSION Act funding to take center stage in upcoming 2020 budget battles. Federal News Network. February 26, 2019. Accessed October 3, 2024. https://federalnewsnetwork.com/veterans-affairs/2019/02/va-mission-act-f...
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